1

Federal Pharmacy 2013

Senior Leaders’ Perspective

CAPT Deborah Thompson, USCG, USPHS

COL John Spain, USA

Mr. Tim Stroup, DVA

CDR Mike Crockett, USPHS, on behalf of RADM Scott Giberson

CPE Information and Disclosures

Mr. Tim Stroup, COL John Spain and CDR Mike Crockett declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. CAPT Deborah Thompson discloses ownership of Cellceulix Corporation stock.

The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Learning Objectives

• Discuss the importance of federal pharmacy collaboration. .

• Identify collaborative initiatives among the federal services related to the continued evolution to the patient-centered practice model, medication therapy management, and polypharmacy.

• Discuss current challenges and opportunities facing federal pharmacy.

• Describe why the present is a critical time in federal pharmacy.

Self-Assessment Questions

1. Why has the Coast Guard Electronic Health Record not been implemented to date?

2. The Mission of the VA is to Honor America’s Veterans by providing exceptional health care that improves their health and well being. True/False

3. What are examples of federal pharmacists scope of practice?

CAPT Deb Thompson, USPHS/USCG

Pharmacy Program Coordinator/Consultant

USCG Update

Healthcare to a System of Health:

Optimizing Opportunities and Integration

COL John Spain PharmD BCPSArmy Pharmacy ConsultantJohn.spain1.mil@mail.mil

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Agenda

• Strategic Direction

• Healthcare System of Health

• Opportunities

• Integration

• Moving Forward Together

• Questions

“Strategy Abhors a Vacuum”

Strategic Direction: Military Health System

Balance

VA Guiding Principles: People Centric, Results Driven, Forward Looking

Strategic Direction:Army Medicine

Strengthening the health of our Nation by improving the health of our Army

The function of protecting and developing health must rank even above that of restoring it when it is impaired.

Hippocrates

Healthcare System of Health

• Strategic Framework: Create Capacity, Enhance Diplomacy, Improve Stamina

• Operational Approach Performance Triad: Activity, Nutrition, Sleep

• Army Medicine 2020: Impact the Lifespace– 525,600 minutes in a soldier’s year

– 100 minutes of contact with healthcare

Health.

3

Opportunities

• Polypharmacy

• Recapture

• Patient Centered Medical Home

• OTSG Pharmacy Top 3

Polypharmacy(>4 meds with 1CNSD/Psych)

Recapture: Retail MTF/Mail

• Community-Based– Primarily distribution focused

– Target for clinical pharmacist expansion (1:6500)

• Patient-Centered– Wellness/MTM focused

• Soldier-Centered– Polypharmacy focused

– Priorities: 1>2

– 2? >(clinical decision)

Medical Home

High Users

≥ 10 visits to PC (≥ 3 ED) last 12

months

PharmacyBenzodiazepines, Opioids and Psychotropics

Chronic Pain or Behavioral

Health Dx

e.g. Depression,

Anxiety, PTSD

1

2

2

2**Concurrent use opiods AND any other drug class listed

OTSG Pharmacy Top 3:Enterprise Objectives

1. Funded Pharmacist authorizations within the Medical Home (1:6500)

2. Medication reconciliation and education completed by pharmacy at the time of discharge from hospital for all polypharmacy patients with new medication orders

3. Allergy & adverse drug reaction check; first time use medication review, and show & tell checks occur at each outpatient pharmacy encounter

Integration (Service/VA)• Knowledge: DHA Sharing Group, PfP

• Information Sharing: PEC/PVC

• Information Systems: IEHR (Pharmacy Module)

• Training: GME/Technician training

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Knowledge

• Defense Health Agency Working Group -Pharmacy

– Opportunity for consolidating services/product lines

– Consider purchase optimization, formulary harmonization and staffing/points of service options

• Partnership for Patients (PfP)– HHS initiative; Services and JTF Collaboration

– Reduce harm by 40% (VTE, CAP, SSI, Falls, ADE)

– Reduce readmissions by 20%

• Federal Pharmacy Collaboration Council– Position expectations (PACT/PCMH/Home Port)

– Sourcing optimization

Information Sharing

• Pharmacoeconomic Center– Patient Safety: Sole Provider/DUE program

management

– Formulary management/national contracts

– Billing discrepancies/claims adjudication

– Deployment prescription support

• Pharmacovigilance Center– FDA alert notification with preliminary impact

assessment

– Adverse effect signal detection and analysis

– Translate clinical concerns to action (DUEanalysisHCP/patient notificationpolicy/COA to address)

o Adherence metric for inclusion into PCMH model

Information Systems

• Integrated Electronic Health Record– AHLTA templated Polypharmacy review AIM form

– VA PBM PharmD Project model

• Inventory Management – iEHR pharmacy module

• Relay Health®

– Virtual MTM

• Smart Phone Technology– Adherence

– Education

• Portland VA: APHID

Training

• Pharmacy Residencies– National Capital Consortium (Navy & Army)

– Shared residency rotation opportunities

• Technician Training– Medical Education and Training Campus (METC):

combination of all Services & Coast Guard training

– Computer-based collaborative effort between the DOD & VA for use in initial and continuing education (~40 online courses).

– Cornerstone of Anatomy & Physiology training at the METC

– MOA with VA to share technician externship sites

Moving Forward Together…“It’s incredibly important to look at

how we’re going to work with the

VA, not just pass our patients over

to the VA”…

…”That actually reaches from the

Military to the VA and through

Communities throughout the land”...

…”Their care is representative of their sacrifice”…

National Alliance for Patient Medication Information Standardization

• Includes: DOD, VA, and Indian Health Service

• Establish a National medication reconciliation policy

• Baseline medication reconciliation criteria

• Define future electronic medical record requirements

• Congressionally mandated educational series• “Medication Image Library (MIL) Pharmacist”

• “Challenges with Medication Information Management in the Homeless Vet Population“

• “The Dual Care Patient"

• “Minimally Disruptive Medicine”

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“Irreversible Momentum: the synergy of our ongoing and our past accomplishments, our initiatives, our progress, and most importantly the depth of our commitment and the weight of our achievements, will demand a concerted, unified effort.”

- Gen Eric ShinsekiArmy Chief of Staff

Secretary of Veterans Affairs

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Pharmacy Benefits Management Services Department of Veterans Affairs

March 1, 2013

Timothy J. Stroup, BS Pharm, FAPhA, FASHP

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Briefing Purpose

• Overview of the VA Pharmacy Benefits Management Services (PBM) office

• Details on selected services PBM provides to Veterans and staff

• Assessment of PBM priorities, challenges and accomplishments

PBM Organizational Alignment

Office of Patient Care Services

Veterans Health Administration

Pharmacy Benefits Management Services (PBM)

Hines, IL PBM Office

Meds-by-Mail Office

Murfreesboro

Consolidated Mail Outpatient Pharmacies

Charleston

Chelmsford

Emergency Pharmacy Services

Formulary Management

Dallas TucsonLeavenworth

Great Lakes

VACO PBM Office

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2929

PBM Locations

•

Tucson

CMOP

Meds-by-Mail

PBM

Great Lakes

Leavenworth

Dallas

Charleston

Chelmsford

Murfreesboro

Dublin

Cheyenne

HinesVACO

3030

VA Pharmacy Benefits Management Services (PBM)

• VA operates a world-class pharmacy benefits management program with demonstrated excellence in several key areas including:– Clinical pharmacy practice (profession benchmark)

– Pharmacy automation (innovator)

– Medication safety (national and international reputation)

– Formulary management (sustained superior performance in access, cost and quality over the past decade)

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3131

• Prescription fulfillment

– 223 outpatient pharmacies (over 1400 access points of care)

– 7 mail order pharmacies

• FY 2012 cost and workload

– 4.8 million VA pharmacy users

– 144 million VA outpatient prescriptions

• 114 million via mail order

• 30 million via medical care facility pharmacies

– $3.463B for outpatient prescription ingredients

– $807M for inpatient prescription ingredients

Outpatient Pharmacy Points of Service, Cost and Workload

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VA Pharmacy Workforce

• ~7,000 pharmacists (VA and contract)

– All staff pharmacists have clinical activities

– Vast majority of clinical pharmacists possess the Doctor of Pharmacy (Pharm D) degree

• ~1000 are board certified in a pharmaceutical specialty

• ~4,300 pharmacy technicians

Source: Veterans Shared Service Center website. Full time staff. Accessed 10/20/09

VA Pharmacy Residency Programs

FY’2011-2012:

Total # of PGY1 Programs: 116

Total # of PGY2 Programs: 65

Total # of Residency Programs: 181

Total # of Residents: 466

Total # of Fellows: 2

33 3434

Drug Formulary Management Process

3535

Objectives of the Formulary Management Process

• Standardize the drug benefit across the VA system to reduce geographic variation in cost and utilization

• Promote appropriate drug therapy

• Improve drug safety

• Improve the distribution of pharmaceuticals

• Reducing drug inventory and acquisition costs

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Principles

• Formulary decisions are based on published medical evidence, not on provider preference

– Decisions are made by practicing VA physicians and pharmacists after extensive reviews of the evidence

• Safety is the top priority, followed by effectiveness

• Cost is the final consideration

– Low cost cannot be a deciding factor if there are concerns over safety and/or effectiveness

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Formulary Features

• VA provides all medically necessary drugs

– National non-formulary access policy

• Single standardized VA National Formulary (VANF)

• Strict reliance on published evidence for decisions

• Newly marketed drugs are reviewed promptly for VANF listing

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VA National Formulary Management Groups

• Pharmacist Executives (VPE) Committee-• 1 Medical Advisory Panel physician

• 1 senior pharmacist from each VISN

• 2 DoD pharmacy benefits managers

• 1 Indian Health Service pharmacist

• 1 National Center for Patient Safety pharmacist*

• Provides operational expertise and oversight

• Members implement decisions within their VISN

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VA National Formulary Management Groups

• VA Medical Advisory Panel (MAP)-

• 12 field-based practicing VA physicians

• 9 VA clinical pharmacists

• 1 VISN Pharmacist Executive

• 1 Department of Defense (DoD) physician and 1 DoD pharmacist

• Provides clinical expertise and oversight

• Physicians have the majority vote

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Formulary Challenges

• Managing the use of newly marketed drugs when little is known about long-term safety

• Inappropriate denial of non-formulary drug requests

• Prescription co-payments for low cost generic drugs

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Non-FormularyDrug Request Process

• Provides access to any medically necessary drug

• Emergency requests are addressed immediately

• Routine requests are adjudicated within 96 hours

– 13.4M (5.4% of total) non-formulary 30-day prescriptions at a cost of $785M (24%)*

– 81% of all requests are approved**

*Source: PBM CDW Outpatient Prescription Data for FY12**As reported by VISNs for FY12

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Formulary Accomplishments

• Evolution from 173 medical center formularies in 1995 to a single national formulary in 2009

• FY 2012, VA saved more than $161 million as a result of a National Pharmacy Efficiency Plan

• Stable individual prescription costs and prescription costs per patient (see following data)

8

$8.00

$9.00

$10.00

$11.00

$12.00

$13.00

$14.00

$15.00

$16.00

$17.00

$18.00

Do

llars

VA Average 30-Day Equivalent RX Ingredient Cost

4343

$12.51 in Q1FY13

$12.92 in Q1FY99

~3% decrease over ~13 years

Cost Per Prescription Trend(Drug Ingredient costs only)

$500

$550

$600

$650

$700

$750

$800

$850

$900

Do

llars

Fiscal Year

VA Average Pharmacy Unique Drug Cost

4444

Cost Per Patient Trend

$719 in FY 2012

~20% increase over 13 years

$599 in FY 1999

(Drug Ingredient costs only)

4545

Drug Expenditure Trends

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

$3.50

$4.00

$4.50

$5.00

Do

llars

in

Bill

ion

s

Drug Expenditures

Total Expenditures Outpatient Expenditures Inpatient Expenditures

4646

Consolidated Mail Outpatient Pharmacies

(CMOPs)

4747

Consolidated Mail Outpatient Pharmacy

• 7 sites: Charleston, Chelmsford, Dallas, Great Lakes, Leavenworth, Murfreesboro & Tucson

• 115 million prescriptions filled in FY12 (79% of all VA RXs)

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Core Functions

• CMOPs provide prescription fulfillment to support VA medical care facility pharmacies, the ChampVAprogram, the San Diego Naval Hospital and numerous Indian Health Medical Centers/Clinics.

– Purchase drugs, supplies and services

– Receive / stock products

– Fill / dispense prescriptions

– Check / verify prescriptions

– Package prescriptions

– Deliver packages to patients’ residences

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4949

CMOP Expenditures/Costs

• Workload 115 million prescriptions/year (FY’12)

– Includes DOD (1 site pilot) and IHS (24 sites)

– 460,000 prescriptions/work day

• Expenditures $2.72 billion/year (FY’12)

– approximately $11 million/work day

• 79% of all outpatient Rx filled in VHA

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Clinical Pharmacy Practice

• The CPPO continues to develop advanced roles of the clinical pharmacist and clinical pharmacy specialist that helps the VA and Veterans medication related problems and better manage disease states

• Pharmacist Scope of Practice– Over 2600 pharmacists with a scope of practice (39%)

– 73% of these pharmacists have post-graduate residencies, board certifications, or other certifications

– 69% spend over 50% of their week in activities related to their scope of practice

• Enhanced Metrics to measure Clinical Pharmacy Activities– Over 3.5M clinical pharmacy encounters in FY12

– Pharmacists practicing at the top of their license performing comprehensive medication management services

Clinical Pharmacy Program Office (CPPO)

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• Medication Reconciliation Across Sites– Standardized process for pharmacists to hold, edit or discontinue prescriptions at

other VA sites

– New process to ensure medication reconciliation of patient’s medications to include clinical pharmacists at both ends

• Pharmacy Systems Redesign Strategies – are developing and rolling out resources and education to facilities on how to approach meaningful systems redesign with the goal of enhancing clinical pharmacy services through staff redeployment.

• Pharmacists Achieve Results with Medications Demonstration (PhARMD) Project

– Development of a clinical reminder tool to standardize documentation of clinical pharmacy interventions across the system

– Use by over 30 VA sites during pilots

• Antimicrobial Stewardship (ASP) – taken a lead role in the implementation of ASP programs across VHA including provision of education, field guidance and sample policies52

Clinical Pharmacy Program Office (CPPO)

Demographics of VA Pharmacists

Of These 2,600

Residency trained = 62%

BPS Certification =

34%

Other Certification =

13%

Residency and/or BPS

certification = 66%

Residency and/or BPS

and/or Other Certification =

73%

Total pharmacists with SOP is over 2,600 (39%)

VHA has approximately 6,700 Pharmacists

Pharmacists with a Scope of Practice

10

Pharmacist SOP by Disease State

941

550509

475

311 305278

180

285

197

978

195

100 121167

10872 54

458

169

54

140

Pharmacists With a Scope of Practice – Growth Over Time

1,945

2,087

2,284

2,473

2,654

1,700

1,900

2,100

2,300

2,500

2,700

2,900

Clinical Pharmacy Encounter Growth

Reference: VA SharePoint Metrics site Dec 2011

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

2007 2008 2009 2010 2011 2012

Number of 160 Encounters (FY07 thru FY12)

160 Secondary

160 Primary

Measuring Clinical Pharmacy Interventions System-Wide in VA

CPS Documentation of Pharmacotherapy InterventionsAnticoagulation InterventionCompliance/Adherence AddressedContraindication to Medication Drug Interaction AddressedDrug Not IndicatedDuplication Of TherapyMedication Interventions Med Reconciliation PerformedNon-formulary Review/ConversionPrevent /Manage Drug AllergyManage Adverse Drug EventNonpharmacologic InterventionTherapeutic Drug Monitoring or Diag EvalDiabetes Interventions or Goal MetHypertension Interventions or Goal MetHeart Failure Interventions or Goal MetLipid Interventions or Goal MetBone Health InterventionsSmoking Cessation Interventions or GoalMetHepatitis C Interventions or Goal Met

PBM designed a clinical reminder tool for roll-out by end of FY13. Project aligns with VHA Transformational Initiatives

Documentation of clinical interventions made by Clinical Pharmacy Specialists (CPS) across VHA, as non-physician providers.

Documents interventions which have demonstrated:

•Potential to reduce harm to patients•Potential cost avoidance to healthcare system

CPS demonstrate the ability to document clinical interventions and therapeutic achievements for specific disease states

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PBM PhARMD Clinical Reminder ToolTool Design and Use

The CPS documents interventions made and when goals achieved

PBM PhARMD Expansion Pilot ResultsApril to September 2012

• Tool utilized by almost 70 pharmacists at 9 VA sites

• Expansion to 4 additional VISNs in VHA in Nov 2012

Metric Results

Number of Interventions made by the CPS

35,589

Number of Patients 17,147

Number of Visits 19,659

Avg. Number of Interventions per visit 1.75(range of 0.5-2.4)

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Type of Intervention

Avg Cost Avoidanceper intervention

(Lee et. al)

Possible CostAvoidance assoc with CPS Interventions

Disease State Medication Interventions $363.73 $4,027,582.29

Additional Medication Interventions $363.73 $468,120.51Drug Interaction $398.97 $31,119.66

Drug Not Indicated $91.88 $10,194.60Duplicate Therapy $169.91 $9,005.23

New Tx for Existing Diagnosis$1,861.46

$1,424,016.90Manage ADE $674.61 $731,277.24

Manage Allergy $289.48 $12,737.12

Total CPS Cost Avoidance $6,714,053.55

PBM PhARMD Expansion Pilot ResultsLinking Cost Avoidance to CPS Interventions

Lee AJ, et al. Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center. Am J Health-Syst Pharm 2002;59:2070-2077

PBM PhARMD ProjectFuture Implications for Use

• Use of tool nationally has multiple implications for the profession of pharmacy and practice within VHA

Opportunities include:

National Benchmarking of pharmacy interventions and outcomes

National, VISN and Local Cost justification of new and existing pharmacists

Comparison of pharmacy interventions in VHA to other healthcare organizations

Use in OPPE process for Scope of Practice

Creation of Clinical Pharmacy Staffing tools and models

Identification of best practices for more rapid sharing of information

Identification in potential gaps in care that may exist at facilities 62

Antimicrobial Stewardship

• Nationally Identified area of need

• Close collaboration between Infectious Disease Physicians and Pharmacy

• Created business plans, sample policies, practice based tools and education that have been rolled out nationally.

• Moving toward national requirements for ASP programs at every site with “certification” based pharmacists as the key professional to manage

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Pharmacy Practice Priorities

• Integrate advanced clinical pharmacist specialist services into the care of special emphasis populations and high risk patients

• Integrate basic clinical pharmacist specialist services into all VA healthcare delivery environments

• Reduce medical center variability in staffing for clinical pharmacist specialists by creating and publishing staffing standards

6565

Pharmacy Practice Challenges

• Expanding the use of clinical pharmacist specialists in all care settings

• Re-aligning pharmacists from drug distribution functions to drug therapy management functions

• Re-training and re-aligning existing clinical pharmacist specialists for practice in priority areas (e.g., mental health, polytrauma)

6666

Pharmacy Recruitment and

Retention

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VA Pharmacist Retention Statistics

• Pharmacists eligible for retirement• 49% of all Pharmacy Supervisors by 2018

• 55% of Pharmacy Supervisors GS-14 & GS-15 are eligible for retirement

• 73% of Pharmacists GS-15 are eligible for retirement

• 33% of Pharmacy Chiefs

• VA pharmacist losses 2012 to 2018: est. 2,754

• VA pharmacist hires 2012 to 2018: est. 3,262

• FY 2011 VA pharmacist quit rate1st 2 years of employment: 15.5% (total VHA workforce: 19.5%)

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Workforce ManagementInitiatives

• Pharmacy manager mentoring program

– Mentor training and certification

– Pairing new pharmacy managers with seasoned senior managers

• Post graduate pharmacist education

– VA is professional leader in American Society of Health System Pharmacist accredited residencies

• Pharmacist Recruitment & Retention office

• VA/DoD pharmacy technician on-line training program (Joint Incentive Fund project)

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Recruitment & Retention Tools

• Recruitment Incentives

• Retention Incentive (up to 25% of base pay)

• Relocation Incentives

• Employee Debt Reduction Program (EDRP)

• Employee Incentive Scholarship Program (EISP)

• VA Learning Opportunities Residency (VALOR)

– 120 positions approved in FY 2013

• PL 110-84: College Cost Reduction Act of 2007

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PharmacyRe-Engineering

(PRE) and Informatics

PRE MOCHA Dosing 2.0

• First increment of dosage checks

• Introduces the Maximum Single Dose Check for simple and complex orders for both Outpatient Pharmacy and Inpatient Medications applications.

• Currently in Production at 6 test sites

• National deployment will be accomplished in 5 phases, following CPRS 29 beginning with approximately 15 VistA sites in February 2013

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MOCHA 2.0 Site Readiness

• Training provided - Multiple live and recorded sessions, training manuals, FAQ document

• Sites will be provided with “Quick Order Report” for analysis of potential incompatibilities with free-text or local possible doses (ADPAC/PI Review)

• Sites need to plan an approach to manage orders which exceed recommended dosages. e.g. Methadone greater than 10mg

• Sites should ensure that multi-ingredient medications have a 1:1 Orderable Item/Dispense Drug relationship (ADPAC/PI Review)

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Emergency Pharmacy Services (EPS)

7474

Purpose

• To provide access to pharmaceuticals for Veterans and staff during a natural disaster, pandemic or other public health emergency

• Coordinate maintenance of emergency “all-hazards” caches at VA medical care facilities

• Develop VA mobile pharmacy capability

• Trained cadre of volunteer VA pharmacists and pharmacy technicians that can and have deployed with the mobile pharmacy

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VA Mobile Pharmacies

Mobile Pharmacy #1• The first VA mobile unit (MP#1) was purchased in April 2007

• Deployed in September 2008 for Hurricane relief

7676

Mobile Pharmacy #2

• The second mobile pharmacy is undergoing configuration for VA communication security requirements

Mobile Pharmacy #3

77

• Newest Member of the Mobile Pharmacy Fleet• Pharmacy, Rest Area & Sleeping Quarter

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Emergency PharmacyPriorities

• Coordination of cache maintenance with VA facilities, Office Public Health (OPH) and Office of Emergency Management (OEM).

• Collaboration with the (OPH/OEM) for periodical cache re-evaluation.

• Establishment, development and maintenance of mobile pharmacy capabilities and deployment strategies.

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Emergency Pharmacy Challenges

• Securing sufficient space within medical care facilities to expand cache storage

• Securing sufficient warehouse space to support the centralized storage of:

– Antivirals

– Anthrax Countermeasures

– Respirator Masks

– Various Vaccines

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Emergency Pharmacy Accomplishments

• Successful construction and acceptance of Mobile Pharmacy #3. Contracted for two additional units.

• Successfully deployment of increased amounts of influenza antivirals to VA cache sites

• Participation in the Food and Drug Administration Shelf Life Extension Program

– Testing to extend the expiration date of expensive pharmaceuticals

– In excess of $110M in SLEP cost avoidance to date

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8181

Medication Reconcilation

VA Medication Reconciliation Initiative

82

Safe, Effective, Efficient, and Patient Centered Medication Information Management

83

VA MedicationReconciliation Directive

Definition

The Joint CommissionReconciliation Revised

Patient Safety Goals

Obtaining medication information from patient, caregiver, and/family.

NPSG.03.06.01 EP1: Obtain information on the medications the patient is currently taking

Comparing this to the medication information available

NPSG.03.06.01EP3: Compare the medication information

Communicating with and providing education to patient, caregiver, and/or family regarding this information.

NPSG.03.06.01EP4: Provide the patient (or family as needed) with written information.

Communicating this with the healthcare team(s).Addendum for 2013: Definition of Essential Medication Information for Patient Medication Lists (Draft)

PC.04.02.01: Information about treatment is provided to other service providers

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Medication Reconciliation Initiative: Transitioning to

Patient Centered Medication Information Management“Its more than a list”

• Foster a team based, ever improving, patient centered approach to medication information management, including Medication Reconciliation

• Direct development of software tools for Patient, Caregiver & their Healthcare Teams:

– Obtain, assemble, calculate, alert, retrieve & store medication information

– Standardize the content and display of medication information

– Promote Patient Generated Data

• Ensure that the Veterans Voice has a place in the chart

• Allow for bidirectional communication, validation and recognition of patient data

• Encourage a customized care plan

– Embed monitoring capabilities

– Interoperable across all innovations

• Connect to the non VA healthcare organizations

• Comply with Meaningful Use

• Align with Patient Protection and Affordable Care Act Medication Information mandates

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15

Medication Reconciliation is part of

Medication Information Management

Medication Reconciliation

• What medication(s) did the Healthcare Team(s) recommend?

• What is the Patient actually taking?

• What is the final updated Med List now?

• Does the Patient and the Healthcare Team have this updated Med List?

• Can we prove in the chart that this has been done?

Medication Information Management

• Add Patient Context, for example:

– Why is he/she taking medications differently?

– What are his/her preferences in medications?

– Are there any barriers to taking his or her medications?

• Add Staff Context, for example:– Why are medications

different on admission?– Who is managing this

medication?85

Patient Centered Medication Information Management: 2013 Programs

• Virtual Medication Use Crisis Conference*

– Quarterly 4 Hour Series

– Tracks include Partnering with Patient/Caregiver, Medication Information Management, Optimizing Resources, and Leveraging Teams and Transitions

• External Peer Review Process (EPRP) Pilot collecting National Medication Reconciliation metrics that align with VA Medication Reconciliation Directive

• Monthly Meetings and Projects

– Shared Strong practice shared in documentation, education, monitoring, policy, and change management to help meet NPSG.03.06.01

– Active SharePoint site, educational posters, pamphlets, videos, presentations

• Cross-Program Office Projects:

– VA National Alliance for Patient Medication Information Standardization*

– Emergency Department/Urgent Care Center Medication Information Taskforce

– Interprofessional Medication Information Management Education Module*

• May is Medication Reconciliation Awareness Month*

• Joint efforts with Department of Defense (DoD), TriCare, and Indian Health Service

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Pharmacovigilance and Drug Surveillance in the

Department of Veterans Affairs: Focus on VAMedSAFE

VA PBM/ VA Center for Medication Safety - VA MedSAFE Overview

• Medication Safety Goals and Programs

• Drug Surveillance/ Rapid Cycle Evaluations

• Drug Surveillance/VA ADERS

• Risk Reduction

GOAL of VAMedSAFE Program

• Track and evaluate high risk agents, high volume agents, and NMEs with potential risks in the Veteran population

• Determine rates and risks of ADEs associated with specific agents

• Maintain VA’s national drug safety program with emphasis on:

– Utilizing integrated databases as the foundation of the VA comprehensive pharmacovigilance program

– Enhancing spontaneous ADE reporting for system based changes and enhancement of drug safety efforts

• Collaboration on medication safety efforts with other Federal Agencies

Medication Safety Programs

• Drug Surveillance– Rapid Cycle Database Evaluations

– VA ADERS

• National MUEs

• Risk Reduction/MUET

• Medication Safety Communication

16

Selected Examples of VA Medication Safety Surveillance-Rapid Cycle

Evaluations

• Antipsychotics• High Dose Statins• PPIs• Opioids• Prasugrel• Natalizumab

• Dronedarone

• Varenicline

• Dabigatran

• Vaccines

• Bisphosphonates

• Protease Inhibitors (for Hepatitis C)

VA ADERS (Adverse Drug Event Reporting System)

– Best Practice: Cited by Institute of Medicine CEO Checklist for High Value HealthCare

– Direct ADE/ADR reporting to FDA MedWatch, CDC/FDA VAERS, VA ADE Database

– Web-based reporting application

– Available in all VA Facilities (151 facilities from 22 VISNs – 21 VISNs plus CMOP)

– Through 1/16/2013: 334,519 reports and 474,903 symptoms (reactions)

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Risk Reduction

• Medication Use Evaluation Tracker (MUET)– Web-based application

– Focus Appropriate and Safe use of medication

• High risk populations

• High risk medications

– Identifies patients at potential risk for facilities to review/evaluate/intervene

– Tracks interventions

93 Risk Reduction Projects(Selected Example)

• Nifedipine (short Acting) – Prototype

• High Dose Vitamin E

• Alpha Blocker Monotherapy

• LABA Monotherapy

• Ketoconazole/Simvastatin

• High Dose Zolpidem

• Glyburide in Elderly with Renal Insufficiency

VA PBM Warfarin INR Reports

• Monthly reports at:– National, VISN, Facility level

• Track and trend INR results

• Identify areas for improvement

• Review processes

• Network with other facilities

95

VA PBM Warfarin INR Reports

96

Trend: Decreasing % of patients with no INR in 6 weeks

17

ADE Trigger Pilots

• VAi2 Innovations Grant

• Working with industry to develop a software program that will proactively identify Veterans “at risk” for an ADE

• Goal is to take action before an ADE occurs

• Pilots on going at several medical centers

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RX Label Redesign

• Awarded an Innovation for the Advancement of Patient-Centered Care grant for “Improving Veteran health-literacy and safety through implementation of a novel, evidence-based, patient-centered outpatient prescription label”.

• Joint Initiative with National Center for Patient Safety

• National study to evaluate Veterans’ and staff understanding of current VA prescription labels, and to use results and evidenced based literature to create a new, safer label.

• Currently testing redesigned labels in VISNs 6, 7 and 8

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Safe Disposal

• National education pamphlet for safe drug disposal in the home– Available on VA A-Z health index web page

• Piloted medication return envelopes– Removes unwanted/unneeded medications from

the home, reduce risk of poisonings– High Veteran Preference (99%)– Prevented 10 tons of pharmaceuticals from

entering landfill/water supplies– Funding obtained for national roll-out

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Meds-by-Mail and Other Programs/Initiatives

PBM Meds by MailProgram Overview

• Mission: Provide a comprehensive outpatient mail pharmacy benefit for the CHAMPVA program. Pharmacy locations in Cheyenne, WY and Dublin, GA (136 FTEE positions)

• Overview: Began as a pilot in 1995 between the HAC, L-CMOP, and KC VAMC; limited to patient s in Oklahoma. Expanded in the late 1990’s to seven mid-western states and Cheyenne VAMC replaced KC. Program expanded nationally in 1999. Second site in Dublin established in 2004. PBM took over operations in October 2008. Benefit by law must be similar to TRICARE in prescription coverage. No co-pay for the beneficiary.

FY 2012 Summary• Prescription Workload: 2.54 million

• Patients Served: 658,000

• Call Center Operations: 344,000 calls received

• Mail Center Operations: 612,000 mail pieces processed

PBM Virtual Prescription Services

The Partnership 

• Began  as a pilot in FY2011

• PBM Meds by Mail Program

• Two VAMC’s: Tennessee Valley Healthcare System (TVHS) Pharmacy; Mt. Home

• Compensation and Pension Records Interchange (CAPRI) national team

The Pilot

• Remote “virtual” prescription verification of pending file

• Access local VAMC VistA through novel software application CAPRI

• No additional equipment/hardware

• Memorandum of Understanding

The Outcomes

• Impact on costs and resources (e.g., overtime, comp time)

• Staffing adjustments and utilization

• Prescription processing time

• CAPRI functionality

102

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PBM Virtual Prescription Services

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Current Sites:

1. VA TVHS, Nashville, TN (Jan 2011)

2. VAMC Mt. Home, TN (Jun 2011)

3. VAMC Portland, OR(Nov 2011)

4. VAMC Cincinnati, OH(Dec 2011)

5. VAMC Long Beach, CA (Feb 2012)

6. VAMC Minneapolis, MN (Jun 2012)

7. VAMC Philadelphia, PA (Jul 2012)

Workload (Rx’s Verified):

• Q1 FY12 85,737

• Q2 FY12 146,457 (up 71% from Q1)

• Q3 FY12 201,438 (up 38% from Q2)

• Q4 FY12 224,287 (up 11% from Q3)

• Total FY12: 657,919 (up 756% from FY11)

• Total FY11: 76,855

Potential Future Sites:1. VAMC Loma Linda, CA*2. VAMC Hines, IL3. VAMC Ann Arbor, MI4. VAMC Seattle, WA*5. VAMC Roseburg, OR6. VAMC Memphis, TN7. VAMC Denver, CO

Average Rx’s Processed per Hour• Q1 FY12 93.66 Rx/hr• Q2 FY12 93.20 Rx/hr• Q3 FY12 92.17 Rx/hr*• Q4 FY12 104.33 Rx/hr**• Total FY12 96.10 Rx/hr (up 8% from

FY11)• Total FY11 88.99 Rx/hr

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PBM Collaboration withOther Federal Agencies

• Department of Defense (DoD)

• Coast Guard (DHS/CG)

• Indian Health Service (PHS/IHS)

• Bureau of Prisons (DOJ/BoP)

• Food & Drug Administration (FDA)

• Drug Enforcement Administration (DEA)

• Centers for Disease Control (CDC)

• National Institutes of Health (NIH)

• National Library of Medicine (NLM)

• United States Postal Service (USPS)

• Federal Pharmacy Collaboration Council (VA, DoD, HHS, etc)

United States Public Health Service -Working Together to

Advance Health

CDR Mike Crockett

Chair, Pharmacist Professional Advisory Committee

Other =  AHRQ, CDC, DOD, CMS, HRSA, NIH, OS, SAMHSA

U.S. Public Health Service Commissioned Corps (6700)• 25 Agencies, 11 Departments

Commissioned Corps Pharmacists (~1150)• 13 Agencies, 5 Departments• Collaboration with DOD/VA Pharmacy in multiple venues

PHS Federal Pharmacy Network

3

2

Federal Pharmacists are essential to health care access and delivery in the United States;

recognized as health care providers of patient-centered primary and specialty care, and as trusted public health leaders. As experts in

medication use and comprehensive pharmacy services, we promote wellness, prevent and manage disease, ensure patient safety, and

optimize health outcomes in collaboration with the health care team.

Federal Pharmacist Vision Federal Pharmacist Scope of Practice

• Recognized health care providers / public health professionals

• Hold key positions in health leadership

• Practice to the maximum extent of licensure

• Effectively prevent and manage disease

• Function in a wide array of practice roles including regulatory science, policy development, epidemiology, emergency response, global health etc

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Avenues of Collaboration

• Federal Pharmacy Collaboration Council (FPCC)

• Federal Chiefs Meetings (APhA, ASHP)

• Agency-specific initiatives (i.e. IHS/VA)

• Individual Initiative

– Publications

– Agency to Agency Innovation

– Specific Projects

– Join in state project (appropriately as consultant)

Innovation and Leadership

• Indian Health Service (IHS)

– CMOP Update/Expansion with VA

– National Clinical Pharmacy Specialist (NCPS) expanding

• Bureau of Prisons (BOP)

– National HIV/Hepatitis Program

– BOP Clinical Pharmacy Services, Collaborative Practice Agreement Technical Guidance

• Food and Drug Administration (FDA)

– Initiatives

– Legislation

– Public Meetings

Innovation and Leadership• Health Resources and Services Administration (HRSA)

– Patient Safety and Clinical Pharmacy Services Collaborative• Collaboration with Centers for Medicare and Medicaid

Services• Expanded into over 80 new communities nationwide• Over 230 teams from 48 states

• CDC– National HIV/AIDS Strategy

– Public/Private partnerships to advance patient-centered HIV care

– White Paper developed with APhA on Chronic care, scope

• PHS Pharmacy in DoD– Pharmaceutical Operations Directorate administers $7.5 Billion

TRICARE pharmacy benefit program serving 9.7 million

– Expanded immunization availability

– Recognition of RADM McGinnis

DHHS/PHS Pharmacy-related Initiatives

• Million Hearts Campaign

• Partnerships for Patients

• Med Adherence Call-to-Action from the SG

• HHS Adverse Drug Events Steering Committee

• HHS Multiple Chronic Conditions (MCC) Working Group

National Prevention Strategy

• Chair, US Surgeon Gen

• Extensive stakeholder s

• Focus from sickness and disease to prevention and wellness

• U.S. PHS Pharmacy Prevention Strategy

– Increase outreach to patients through all settings

– Integrate prevention interventions and care

– Maximize impact through expertise, capacity, and access

2012-13 Corps Response Missions

• Superstorm Sandy– Over 450 officers; 74 pharmacists

• Sandy Hook, Connecticut– Over 20 MH providers

• Saipan (Northern Marianas)– Strike Team (OIC Pharmacist –

RADM Bina)

– 2 additional pharmacists

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Advance the Profession to Improve the Nation’s Health

• Publications / Articles• Pharmacy Report to the Surgeon General• NY Times Article on use of Pharmacists:

– http://www.nytimes.com/2012/12/16/opinion/sunday/when-the-doctor-is-not-needed.html?nl=todaysheadlines&emc=edit_th_20121216

• US Medicine Outlook 2013 Article on Pharmacy• Washington (state) Attorney General

opines on health care provider status• Pennsylvania courts decision in

Medical Records • State association collaborations• CMS Part A Regulation• OPPORTUNITY

Key Points

• PHS Pharmacy shares the vision of pharmacy and Federal pharmacy

• PHS Pharmacy is focused on advancing the health of the Nation and the practice of pharmacy

• PHS Pharmacy embraces our diversity of practice and uses this as a strength in times of response

Answers to Self-Assessment Questions1. Why has the Coast Guard Electronic Health

Record not been implemented to date?

Answer: Complex matrix of critical relationships, each with approval processes involved.

2. The Mission of the VA is to Honor America’s Veterans by providing exceptional health care that improves their health and well being. Answer: True

3. What are examples of federal pharmacists scope of practice? Answer: Trusted health leaders, who are recognized as health care providers and public health professionals.

CAPT Deborah Thompson, USCG, USPHSDeborah.J.Thompson@uscg.mil

(202) 475-5181

Mr. Tim StroupTim.Stroup@va.gov

(913) 683-0489

CDR Mike Crockettmcrockett@bop.gov

318-765-4684